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Background: The aim of this study was to investigate the process of end-of-life decision-making regarding people with intellectual disabilities (ID) in the Netherlands, from the perspective of physicians. Methods: This qualitative study involved nine semi-structured interviews with ID physicians in the Netherlands after the deaths of patients with ID that involved end-of-life decisions. The interviews were transcribed verbatim and analysed using Grounded Theory procedures. Results: Four main contributory factors to the physicians decision-making process were identified, three of which are related to the importance of relatives' wishes and opinions: (1) "Involving relatives in decision-making." As they had assessed their patients as lacking capacity, the physicians gave very great weight to the opinions and wishes of the relatives and tended to follow these wishes. (2) "Delegating quality of life assessments to relatives." Physicians justified their end-of-life decisions based on their medical assessment, but left the assessment of the patients' quality of life to relatives, despite having their own implicit opinion about quality of life. (3) "Good working relationships." Physicians sought consensus with relatives and paid care staff, often giving greater weight to the importance of good working relationships than to their own assessment of the patient's best interest. (4) "Knowledge of the patient's vulnerabilities." Physicians used their intimate, long-standing knowledge of the patient's fragile health. Conclusions: In order to take a more balanced decision, physicians should seek possibilities to involve patients with ID themselves and other stakeholders which are important for the patients. Physicians who have known the patient over time should rely more on their own knowledge of the patient's needs and preferences, seek the input of others, and openly take the lead in the decision-making process. (Contains 1 figure and 1 table.)

Background: Since the 1990s, people with intellectual disability (ID) in the Netherlands have been moving from institutions to supported accommodation in the community. The Government is in need of recent data on the numbers of these people, to ensure adequate care provision and funding. This paper reports on the prevalence of people with ID in the Netherlands. The research question was: what is the lowest and highest estimation of prevalence of people with ID in the Netherlands? Methods: Two extrapolation methods were used, each consisting of a number of stages, using general practice databases and ID care services records. Results: The prevalence of people with ID in the Netherlands was 0.7% (111,750 persons). Other assumptions yielded 0.54-0.64%. Arguments for the two extrapolation methods and the lowest and highest estimation of prevalence are discussed. Conclusions: Compared with 1988, there has been a slight decrease in the prevalence of people with ID in the Netherlands, even though we included all age groups and even people with ID of who were not included in ID care services records. By using general practitioner databases it was possible to identify these not registered people with ID.

Background: Current changes in care philosophy and diversity in care arrangements caused the need for a new estimate of the number of people with intellectual disability (ID), based on recent data. Previous estimates were based on client registrations, which was thought unreliable at this time. This manuscript studies the question how many people with ID can be found in (part of) the Netherlands. Methods: Identification of people with ID through a combination of general practice (GP) data bases and service registrations in the province of Limburg. Results: The prevalence of people with ID appeared to be between 0.64% and 0.70%. About 0.21-0.27% were living with family or on their own; 55% of them did not use common ID services. Conclusion: Results are based on a combination of identification methods. Thirteen per cent of uncertain cases led to minimum and maximum estimates of the population. Limitations of the method and alternative ways of data collection are discussed.

Background: Advance care planning (ACP) is a process in which professionals, patients and their relatives discuss wishes and options for future care. ACP in the palliative phase reduces the chance that decisions have to be taken suddenly and can therefore improve the quality of life and death. The primary aim of this study is to explore how ACP takes place in cases of people with intellectual disabilities (ID). Method: Medical files were analysed, and interviews were held in six care organisations for people with mild to severe ID. The data concerned people with ID (n = 30), 15 in the palliative phase, identified using the 'surprise question', and 15 who had died after an identifiable period of illness. Additional pre‐structured telephone interviews were conducted with their relatives (n = 30) and professionals (n = 33). Results: For half of the people with ID who had died, the first report in their file about palliative care (needs) was less than 1 month before their death. Professionals stated that ACP was started in response to the person's deteriorating health situation. A do‐not‐attempt‐resuscitation order was recorded for nearly all people with ID (93%). A smaller group also had other agreements between professionals and relatives documented in their files, mainly about potentially life‐sustaining treatments (43%) and/or hospitalisation admissions (47%). Relatives and professionals are satisfied with the mutual cooperation in ACP in the palliative phase. Cognitive and communication disabilities were most frequently mentioned by relatives and professionals as reasons for not involving people with ID in ACP. Conclusions: Advance care planning in the palliative phase of people with ID focuses mainly on medical issues at the end of life. Specific challenges concern a proactive identification of changing needs, fear to initiate ACP discussions, documentation of ACP in medical files and the involvement of people with ID in ACP. It is recommended that relatives and professionals should be informed about the content of ACP and professionals should be trained in communicating in advance about wishes for future care. [ABSTRACT FROM AUTHOR]

Background: Much research worldwide is focussed on cost containment and better adherence to guidelines in healthcare. The research focussing on professional behaviour is often performed in a well-controlled research setting. In this study a large-scale implementation of a peer review strategy was tested on both test ordering and prescribing behaviour in primary care in the normal quality improvement setting. Methods: We planned a cluster-RCT in existing local quality improvement collaboratives (LQICs) in primary care. The study ran from January 2008 to January 2011. LQICs were randomly assigned to one of two trial arms, with each arm receiving the same intervention of audit and feedback combined with peer review. Both arms were offered five different clinical topics and acted as blind controls for the other arm. The differences in test ordering rates and prescribing rates between both arms were analysed in an intention-to-treat pre-post analysis and a per-protocol analysis. Results: Twenty-one LQIC groups, including 197 GPs working in 88 practices, entered the trial. The intention- to-treat analysis did not show a difference in the changes in test ordering or prescribing performance between intervention and control groups. The per-protocol analysis showed positive results for half of the clinical topics. The increase in total tests ordered was 3% in the intervention arm and 15% in the control arm. For prescribing the increase in prescriptions was 20% in the intervention arm and 66% in the control group. It was observed that the groups with the highest baseline test ordering and prescription volumes showed the largest improvements. Conclusions: Our study shows that the results from earlier work could not be confirmed by our attempt to implement the strategy in the field. We did not see a decrease in the volumes of tests ordered or of the drugs prescribed but were able to show a lesser increase instead. Implementing the peer review with audit and feedback proved to be not feasible in primary care in the Netherlands. Trial Registration: This trial was registered at the Dutch trial register under number ISRCTN40008171 on August 7th 2007. [ABSTRACT FROM AUTHOR]

Little is known about the involvement of nurses in the process of making end-of-life decisions for people with intellectual disability (ID). The aim of this study was to clarify this process from the perspective of nurses. This qualitative study involved nine semistructured interviews with nurses working in chronic care, conducted after the deaths of patients with ID in the Netherlands. The interviews were transcribed verbatim and analyzed using Grounded Theory procedures. The core characteristic of the position of the nurses and of the way they supported the patient was 'Being at the center of communication.' Related categories of topics emerging from the interviews were 'Having a complete picture of the patient,' 'Balancing involvement and distance,' 'Confidence in one's own opinion,' and 'Knowledge about one's own responsibility,' all of which were focused on the patient. This focus on the patient with ID might explain why the nurses could make valuable contributions to such an important subject as end-of-life decisions. People with ID themselves were not involved in the decisions. The nurses were not always aware who was ultimately responsible for the end-of-life decisions. Nurses are in a unique position to support the process of end-of-life decision-making. It is important to use their knowledge and give them a more prominent position in this decision-making process. It should be clear to all involved who is ultimately responsible for making the end-of-life decisions. [ABSTRACT FROM AUTHOR]

Objective The prevalence of multimorbidity has risen considerably because of the increase in longevity and the rapidly growing number of older individuals. Today, only little is known about the influence of multimorbidity on cognition in a normal healthy aging population. The primary aim of the present study was to investigate the effect of multimorbidity on cognition over a 12-year period in an adult population with a large age range. Methods Data were collected as part of the Maastricht Aging Study (MAAS), a prospective study into the determinants of cognitive aging. Eligible MAAS participants ( N = 1763), 24-81 years older, were recruited from the Registration Network Family Practices (RNH) which enabled the use of medical records. The association between 96 chronic diseases, grouped into 23 disease clusters, and cognition on baseline, at 6 and 12 years of follow-up, were analyzed. Cognitive performance was measured in two main domains: verbal memory and psychomotor speed. A multilevel statistical analysis, a method that respects the hierarchical data structure, was used. Results Multiple disease clusters were associated with cognition during a 12-year follow-up period in a healthy adult population. The disease combination malignancies and movement disorders multimorbidity also appeared to significantly affect cognition. Conclusions The current results indicate that a variety of medical conditions adversely affects cognition. However, these effects appear to be small in a normal healthy aging population. Copyright © 2010 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Background: Multimorbidity has been suggested to be associated with a variety of negative health-related outcomes. The present study was designed to evaluate the association between multimorbidity and subjective memory complaints.Methods: This cross-sectional study was based on data obtained from a postal survey designed by the Public Health Service (Gemeentelijke Gezondheids Dienst, GGD) involving 15,188 persons aged 55 years and over living independently in Limburg, the Netherlands. Multivariate logistic regression analyses, adjusted for potentially important covariates, were performed to evaluate the association between self-reported multimorbidity and three outcomes related to subjective memory complaints.Results: Multimorbidity was indeed related to subjective memory complaints. The association between multimorbidity and subjective memory complaints was positively influenced by age. Moreover, multimorbidity was related to the degree of worrying about memory complaints in people who perceived themselves as forgetful. Multimorbidity was also associated with reporting a larger increase in these subjective memory complaints during the past year. In this latter case, multimorbidity had more prognostic capability in men than in women. Psychological distress was related to all three subjective memory-related outcome measures.Conclusions: In our sample, which was representative of the Dutch population, multimorbidity was associated with subjective memory complaints. The relationship between multimorbidity and subjective memory complaints differed between men and women and between age groups. [ABSTRACT FROM AUTHOR]

Introduction: Accurate self-assessment appears to be difficult and, some would propose, even impossible. Recent reviews suggest that peer assessment may be more accurate and that multisource feedback (MSF) may inform self-assessment. We had conducted a series of studies of family physicians in an MSF program including assessments from patients, medical colleagues, and coworkers and self-assessment. Using this body of research, this article explores self-assessment within the social context of multisource feedback and investigates the influence of feedback from peers and others upon self-assessment.Methods: This is a review article in which we synthesized findings of the series of studies with respect to self-assessment, used conclusions to propose a model for self-assessment within a social context, and suggest practical and research implications.Results: Physicians compared peers' and others' assessment feedback with global self-perceptions of performance. Negative feedback, especially from medical colleagues, that was inconsistent with self-perceptions was not readily reconciled with self-assessments. Multiple internal and environmental factors influenced reconciliation and assimilation of negative feedback. Reflection upon feedback and self-perceptions appeared to be instrumental to reconciliation, and reflection could be facilitated.Discussion: We propose a model of 'directed' self-assessment to facilitate the integration of external feedback, especially negative feedback, with self-perceptions and enable its use for practice improvement. Implications for education and research include increasing understanding of ways physicians assimilate external feedback and of the role of educators as facilitators of 'directed' self-assessment and self-learning to assist physicians in integrating external feedback. [ABSTRACT FROM AUTHOR]

van den Akker M, Schuurman A, Metsemakers J, Buntinx F. Is depression related to subsequent diabetes mellitus? Acta Psychiatr Scand 2004: 110: 178–183. © Blackwell Munksgaard 2004. To compare the risk of developing diabetes mellitus (DM) in the general population between subjects who had a depression and subjects who never had a depression. Retrospective cohort design. People with depression were diagnosed with a depression between 1975 and 1990; controls never had a depression. Both groups were followed for a diagnosis of type II diabetes until 2000. Data on 1334 depressed and 66 670 non-depressed subjects were available from a large general practice-based database. No overall relation was found, but among males below age 50 there was a 78% increase in the rate of development of DM compared with non-depressed patients (hazard ratio 1.78, 95% CI: 1.21–2.62). Depression in males between the age of 20 and 50 years is related to an increased risk of developing DM. [ABSTRACT FROM AUTHOR]

Background: There is little evidence about the management and course of chronic low back pain in primary care.Objectives: Our aim was to describe the course of chronic low back pain and the performed diagnostic and therapeutic procedures for patients with chronic low back pain in general practice.Methods: Twenty-six GPs involved in the Registration Network Family Practices participated in this prospective follow-up study. All patients and GPs were asked to complete questionnaires at baseline and at 4, 8 and 12 months follow-up.Results: The GPs provided information about diagnostic and therapeutic procedures concerning 524 patients with chronic low back pain. Diagnostic tests other than history-taking and physical examination were not frequently used. Medication, mostly NSAIDs, was the most frequently used type of treatment (21.6%). The most frequent referrals concerned physiotherapy (16.3%) and neurology or neurologic surgery (6.3%). Information about the course of their chronic low back pain was provided by 368 patients participating in our study. The course of chronic low back pain appeared to be quite stable, as there was only a slight improvement in pain intensity and physical functioning over the 12 months of follow-up.Conclusions: A variety of options for the treatment and referral of chronic low back pain patients is available for and used by GPs. Efforts should be made to establish which diagnostic and therapeutic procedures are the most effective for chronic low back pain. [ABSTRACT FROM AUTHOR]

General practice is an important source of information on the occurrence and distribution of chronic disease in the population. In this study, the burden of chronic illness was expressed as different indices of prevalence. Data were provided by 42 general practitioners in 15 computerized practices, collaborating in the Registration Network Family Practices of the University of Limburg in the Netherlands. Morbidity data concerning the actual health status of 25,357 subjects, as recorded by their GPs, were classified following the International Classification of Primary Care using the diagnostic criteria of the International Classification of Health Problems in Primary Care-2-Defined. The most frequent single disease was asthma (3.5%), while locomotor problems represented the most prevalent category (8.3%). The overall prevalence of chronic disease was 29.4%, with a clear positive correlation with age and, to a lesser extent, with a lower educational level. The ‘social prevalence’ of chronic illness (including individuals related to chronically diseased patients via their households) could be measured in a subset of the database ( = 4577), and amounted to 56%. It is concluded that the role of the GP as a family doctor involved with chronic disease concerns the majority of the general population. [ABSTRACT FROM PUBLISHER]

Background: Factors related to physical health have been implicated in both normal and pathological aging of cognitive abilities. To substantiate this notion, we studied existing morbidity, as diagnosed by the general practitioner according to well-defined criteria, as a potential predictor of cognitive test performance.Methods: A sample of 1360 individuals, aged 24-81 years and living in the community, was stratified for age, sex, and general ability. Active and total morbidity in this group were classified according to the International Classification of Primary Care. Neurocognitive tests were used to assess the domains of verbal memory, sensorimotor speed, and cognitive flexibility.Results: Multiple regression analyses with adjustment for age, sex, and educational level showed both insulin-dependent and noninsulin-dependent diabetes to be negatively associated with all cognitive measures. More specific negative associations were found for chronic bronchitis (performance speed) and presbyacusia (memory). Single or aggregated cardiovascular morbidity (including hypertension) was unrelated to test performance.Conclusions: Existing morbidity as a whole contributes only modestly (up to 3.5%) to total variance in cognitive function. However, some specific, relatively common diseases of the elderly, such as diabetes and chronic bronchitis, may aggravate the age-related decline in cognitive ability. [ABSTRACT FROM AUTHOR]

Reported here are the preliminary results of the second Dutch National Survey of General Practice in which data were collected on all contacts with general practitioners (GPs) during a 12-month period to determine characteristics of patients with intellectual disabilities (ID). Sociodemographic characteristics differed significantly between people with ID and controls, indicating significant differences in morbidity between the two groups (people with ID were found to have more psychological problems, more digestive problems, more ear problems, more neurological problems, and more general and unspecified problems). [ABSTRACT FROM AUTHOR]

Background: Non-response analysis is often restricted to the influence of age, sex and socio-economic status on response status. In this study the health status of responders and non-responders was also compared.Results: Responders were comparable to non-responders with regard to the number of diagnosed disorders as well as to the prevalences of disorders within body systems. Non-responders only showed psychological disorders more often.Conclusion: It is useful to assess the relation between non-response and morbidity patterns in other studies as well, in order to detect selective non-response and bias. [ABSTRACT FROM AUTHOR]

Background: Medical students increasingly participate in rotations in primary care settings, such as general practices. Although general practices can differ markedly from hospital settings, research on the instructional quality of general practice rotations is relatively scarce. Aim: We conducted a study to identify which aspects make a significant contribution to the instructional quality of general practice clerkships, as perceived by students. Method: After completing their general practice attachment, 155 fifth-year medical students filled out an evaluation questionnaire. Exploratory factor analysis and reliability analysis identified clusters of correlated independent variables. Subsequent regression analysis revealed the relations between the reduced set of independent variables and the dependent variable ‘Instructional quality’. Results: Both the quality of supervision and the size and diversity of the patient mix substantially affected students’ experienced instructional quality. Opportunities and facilities to perform independently were correlated with instructional quality, but did not affect the instructiveness directly. Conclusions: Supervision, patient mix and independence are crucial factors for learning in general practice. This is consistent with findings in hospital settings. The perceived quality of instruction hinges on supervision, which is not only the variable most strongly related to instructional quality, but which also affects both the patient mix and students’ independence. [ABSTRACT FROM AUTHOR]

Background: Health problems are more frequently reported in people with intellectual disabilities (ID) in primary care than in the general population. In this study we aimed to explore the basic health needs in persons with ID in order to promote a more proactive approach to health care in primary care settings. Method: The design was a nested (1:5) case-control study across 100 practices in the Netherlands. 868 persons with ID were matched with 4305 controls (age, gender, practice). Results: People with ID consulted their GP 1.7 times more often than control participants. Among the presented health problems, sleep problems and other complaints which could not be classified as a disease were the most commonly reported. Prescriptions of laxatives as well as medication for treatment of peptic ulcers were significantly higher among persons with ID. These data indicate a high prevalence of problems in basic physical functions such as sleeping, eating and defecation in people with ID. Conclusion: We intend to further explore these health problems and the way they are addressed. Through focus group interviews of people with ID and their carers, general practitioners, practice nurses, specialist physicians for people with ID and care providers, we intend to develop models for tailoring primary health care to the specific and basic needs of persons with ID. The presentation will cover the evidence base to date and discuss our further research plans. [ABSTRACT FROM AUTHOR]

A response by S.S.L. Mol and colleagues to a letter to the editor about their article "Symptoms of Post-Traumatic Stress Disorder After Non-Traumatic Events: Evidence From an Open Population Study," which appeared in a previous issue of the journal is presented.

Introduction: Researchers, policy-makers and healthcare professionals often stress the importance of an early dementia diagnosis. Empirical evidence, however, is scarce leading to a lack of consensus on the necessity of diagnosing dementia early. We emphasise the need for a 'timely' diagnosis, that is, one that occurs at the right moment for a person with memory complaints and his/her significant other. As the optimal timing differs between individuals, the implementation of shared decision making (SDM), preferably by the general practitioner (GP), as the start of a diagnostic trajectory, could help to determine this timely moment. SDM, however, is rarely practised with respect to dementia diagnoses. Therefore, in the context of the Shared Decision-Making regarding Dementia Diagnosis project, a patient decision aid (PtDA) for 'timely' dementia diagnosis in general practice will be developed. This protocol will describe the planned before and after evaluation of its implementation., Methods and Analysis: In a mixed-methods pilot study, we will investigate decision-making processes and experiences regarding a diagnostic trajectory before and after the introduction of a PtDA for people with memory complaints, their significant others and their GPs. The 'before group' will receive diagnostics as usual from their GPs. The 'after group' will use the PtDA. We expect the PtDA to increase the level of SDM and to contribute to a timely and personalised diagnostic trajectory. Data will be collected using semistructured interviews, questionnaires and information retrieved from people with memory complaints' medical records., Ethics and Dissemination: This study protocol was approved by the Medical Review Ethics Committee of the Maastricht University Medical Centre. The findings will be published in peer-reviewed international journals and presented at conferences. This study was funded by the public funded Dutch Research Institute for Care and Medical Sciences (ZonMw)., Trial Registration Number: NCT04531956., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Comorbidity is a cause of increased mortality, decreased quality of life and increased use of healthcare services. It is important particularly for physicians and other healthcare providers in primary care settings to evaluate these patients properly. Cardiovascular diseases (CVD) are the most common cause of death from non-communicable diseases worldwide and are characterized by a high level of comorbidities., Objectives: To address the distribution of CVDs and comorbidities across sociodemographic groups and associations between CVDs and comorbidities., Methods: A cross-sectional study was conducted using data of 67 786 patients. Data were collected by the Registration Network Family Practices (RegistratieNet Huisartspraktijken, RNH). Comorbidities were analysed using chi-square and logistic regression analyses., Results: At the time of study, 26.5% of the patients had at least one CVD and 10.5% of patients had two or more CVD diagnoses. The strongest association within cardiovascular diseases were between health failure and arrhythmias (OR: 9.20; 95%CI: 7.78-10.89). Coronary artery disease and hypertension had strong relationship with diabetes (OR: 2.22; 95%CI: 2.02-2.45, OR: 2.22; 95%CI: 2.02-2.45 respectively) and lipid metabolism disorders (OR: 2.04; 95%CI: 1.87-2.23, OR: 2.04; 95%CI: 1.87-2.23, respectively). The strongest associations for cerebrovascular diseases were with epilepsy (OR: 4.09; 95%CI: 3.29-5.10) and arrhythmias (OR: 2.23; 95%CI: 1.99-2.50)., Conclusion: One out of every four patients suffered from at least one CVD. Having one CVD increased the risk of another, co-occurring CVD and a higher number of other chronic diseases.

Background: Previous studies have demonstrated that student ratings of a teachers' performance do not incentivize clinical teachers to reflect critically and generate plans to improve their teaching. Peer group reflection might offer a solution in mediating this change., Aim: To investigate: (a) to which extent clinical teachers perceive self-evaluation, student ratings and peer group reflection effective; and (b) whether additional peer group reflection fosters critical reflection and the translation of feedback into concrete plans of action., Method: We conducted a quasi-experiment, inviting two groups of 10 clinical teachers each (1) to complete a self-evaluation and (2) subsequently examine their student ratings. One group participated in (3) an additional peer group reflection meeting. All participants were finally requested to define plans for improvement and evaluate each activity's effectiveness., Results: Participants perceived all three activities to be effective. Levels of reflection did not differ across the two groups. However, participation in peer group reflection did result in generating more concrete plans to change clinical teaching., Conclusions: Peer group reflection on student ratings shows promise as tool to assist clinical teachers in generating plans for improvement. Future research should focus on whether teaching indeed improves with the introduction of peer group reflection.

Multimorbidity is increasingly the primary concern of healthcare systems globally with substantial implications for patient outcomes and resource cost. A critical knowledge gap exists as to the magnitude of multimorbidity in primary care practice in low and middle income countries with available information limited to prevalence. In India, primary care forms the bulk of the health care delivery being provided through both public (community health center) and private general practice setting. We undertook a study to identify multimorbidity patterns and relate these patterns to severity among primary care attendees in Odisha state of India. A total of 1649 patients attending 40 primary care facilities were interviewed using a structured multimorbidity assessment questionnaire. Multimorbidity patterns (dyad and triad) were identified for 21 chronic conditions, functional limitation was assessed as a proxy measure of severity and the mean severity score for each pattern, was determined after adjusting for age. The leading dyads in younger age group i.e. 18-29 years were acid peptic disease with arthritis/ chronic back ache/tuberculosis /chronic lung disease, while older age groups had more frequent combinations of hypertension + arthritis/ chronic lung disease/vision difficulty, and arthritis + chronic back ache. The triad of acid peptic disease + arthritis + chronic backache was common in men in all age groups. Tuberculosis and lung diseases were associated with significantly higher age-adjusted mean severity score (poorer functional ability). Among men, arthritis, chronic backache, chronic lung disease and vision impairment were observed to have highest severity) whereas women reported higher severity for combinations of hypertension, chronic back ache and arthritis. Given the paucity of studies on multimorbidity patterns in low and middle income countries, future studies should seek to assess the reproducibility of our findings in other populations and settings. Another task is the potential implications of different multimorbidity clusters for designing care protocols, as currently the protocols are disease specific, hardly taking comorbidity into account.

Objective: To systematically review the studies of prevalence, patterns and consequences of multimorbidity reported from South Asia., Design: Systematic review., Setting: South Asia., Data Sources: Articles were retrieved from two electronic databases (PubMed and Embase) and from the relevant references lists. Methodical data extraction according to Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines was followed. English-language studies published between 2000 and March 2015 were included., Eligibility Criteria: Studies addressing prevalence, consequences and patterns of multimorbidity in South Asia. Articles documenting presence of two or more chronic conditions were included in the review. The quality and risk of bias were assessed using STROBE criteria., Data Selection: Two reviewers independently assessed studies for eligibility, extracted data and assessed study quality. Due to heterogeneity in methodologies among reported studies, only narrative synthesis of the results was carried out., Results: Of 11,132, 61 abstracts were selected and 13 were included for final data synthesis. The number of health conditions analysed per study varied from 7 to 22, with prevalence of multimorbidity from 4.5% to 83%. The leading chronic conditions were hypertension, arthritis, diabetes, cardiac problems and skin diseases. The most frequently reported outcomes were increased healthcare utilisation, lowered physical functioning and quality of life, and psychological distress., Conclusions: Our study, a comprehensive mapping of multimorbidity research in South Asia, reveals the insufficient volume of work carried out in this domain. The published studies are inadequate to provide an indication of the magnitude of multimorbidity in these countries. Research into clinical and epidemiological aspects of multimorbidity is warranted to build up scientific evidence in this geographic region. The wide heterogeneity observed in the present review calls for greater methodological rigour while conducting these epidemiological studies., Trial Registration Number: CRD42013005456., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Background: Physicians are frequently confronted with complex health situations of patients, but knowledge of intensive forms of multimorbidity and their development during life is lacking. This study explores patterns and trajectories of chronic health problems of patients with multimorbidity particularly those with more than ten conditions and type and variety of organ systems involved in these patterns during life., Method: Life time prevalence patterns of chronic health problems were determined in patients with illness trajectories accumulating more than ten chronic health problems during life as registered by general practitioners in the South of the Netherlands in the Registration Network Family Practices (RNH)., Results: Overall 4,560 subjects (5%) were registered with more than ten chronic health problems during their life (MM11+), accounting for 61,653 (20%) of the 302,808 registered health problems in the population (N = 87,837 subjects). More than 30% accumulates 4 or more chronic health conditions (MM4-5: 4-5 conditions (N = 14,199; 16.2%); MM6-10: 6-10 conditions (N = 14,365; 16.4%). Gastro-intestinal, cardiovascular, locomotor, respiratory and metabolic conditions occur more frequently in the MM11+ patients than in the other patients, while the nature and variety of body systems involved in lifetime accumulation of chronic health problem clusters is both generic and specific. Regarding chronic conditions afflicting multiple sites throughout the body, the number of neoplasms seems low (N = 3,592; 5.8%), but 2,461 (49%) of the 4,560 subjects have registered at least one neoplasm condition during life. A similar pattern is noted for inflammation (N = 3,537, 78%), infection (N = 2,451, 54%) and injury (N = 3,401, 75%)., Conclusion: There are many challenges facing multimorbidity research, including the implementation of a longitudinal, life-time approach from a family practice perspective. The present study, although exploratory by nature, shows that both general and specific mechanisms characterize the development of multimorbidity trajectories. A small proportion of patients has a high number of chronic health problems (MM11+) and keeps adding health problems during life. However, GP's need to realise that more than one third of their patients accumulate four or more chronic health problems (MM4-5 and MM6-10) during life.

Background: There is a need for follow-up care after stroke, but there is no consensus about the way to organise it. An intervention providing follow-up care for stroke patients and caregivers showed favourable effects on the level of social activities, but no other effects were found. The intervention consists of a maximum of five home visits to patients and caregivers during a period of 18 months post-discharge. The home visits are conducted by a stroke care coordinator (SCC) using a structured assessment tool. The objective of this study was to examine process-related factors that could have influenced the effectiveness of the intervention., Methods: 77 stroke patients, 59 caregivers and 4 SCCs participated in the study. Data on the organisational characteristics of and the satisfaction with the intervention were collected by means of structured assessments, interviews and self-administered questionnaires at 1, 6, 12 and 18 months of follow-up. The intervention was provided between April 2008 and June 2011., Results: Patients received an average of 3.8 home visits (SD 1.4) and 55% of them had a follow-up period of a maximum of 18 months. There were 1074 problems identified and the SCCs initiated 363 follow-up care and referral options. Stroke patients and caregivers were very satisfied with the intervention. The SCCs were satisfied with the assessment tool, but would like to see a structured referral system., Conclusions: The intervention was only partially performed in accordance with the protocol and was positively evaluated by patients, caregivers and SCCs. It is recommended to add a structured referral system to the intervention.

Background: Frailty is often associated with multimorbidity and disability., Objectives: We investigated heterogeneity in the frail older population by characterizing five subpopulations according to quantitative biological markers, multimorbidity and disability, and examined their association with mortality and nursing home admission., Design: Observational study., Participants: Participants (n=4,414) were from the population-based Age Gene/Environment Susceptibility Reykjavik Study., Measurements: Frailty was defined by ≥ 3 of five characteristics: weight loss, weakness, reduced energy levels, slowness and physical inactivity. Multimorbidity was assessed using a simple disease count, based on 13 prevalent conditions. Disability was assessed by five activities of daily living; participants who had difficulty with one or more tasks were considered disabled. Differences among frail subpopulations were based on the co-presence of multimorbidity and disability. Differences among the following subpopulations were examined: 1) Non-frail (reference group); 2) Frail only; 3) Frail with disability; 4) Frailty with multimorbidity; 5) Frail with disability and multimorbidity., Results: Frailty was present in 10.7% (n=473). Frailty was associated with increased risk for mortality (OR 1.40; 95% CI 1.15-1.69) and nursing home admission (OR 1.50; 95% CI 1.16-1.93); risks differed by subpopulations. Compared to the non-frail, the frail only group had poorer cognition and increased inflammation levels but did not have increased risk for mortality (OR 1.40; 95% CI 0.84-2.33) or nursing home admission (OR 1.01; 95% CI 0.46-2.21). Compared to the non-frail, the other frail subpopulations had significantly poorer cognition, increased inflammation levels, more white matter lesions, higher levels of calcium, glucose and red cell distribution width and increased risk for mortality and nursing home admission., Conclusions: The adverse health risks associated with frailty in the general older adult population may primarily be driven by increased disease burden and disability.